[ST-segment elevation acute coronary syndromes: Prehospital management strategies]. / Syndrome coronaire aigu avec élévation du segment ST : stratégies de prise en charge en préhospitalier.

Prehospital management of ST-segment elevation myocardial infarction is a complex issue. Many components are involved, beginning with information of the public on the symptoms of heart attack, up to the choice of the final pathway and destination of the patients, with many intermediate steps including the regulation of emergency calls, the implementation of optimal diagnostic strategies, the choice of reperfusion therapy and of adjuvant medications. In recent years, optimization of these different components has led to improved patients' outcomes in this still life-threatening condition.

[Evaluation of patients' knowledge regarding counsels provided in case of chest pain after an acute myocardial infarction]. / Evaluation des conseils assimilés par les patients sur l'attitude recommandée en cas de douleur thoracique au décours d'un infarctus aigu du myocarde. Conseils ou patient après un infarctus du myocarde.

INTRODUCTION: an early call to the department of urgent medical assistance--Center 15 (SAMU-centre 15) is associated to shortest delays of reperfusion in case of myocardial infarction. However, patients are not always aware of this. OBJECTIVE: to assess the assimilated counsels by patients after an acute myocardial infarction. METHODS: from January 1998 to June 2004, patients managed by SAMU 93 and having benefited from thrombolytic therapy prior to hospitalization and/or primary angioplasty for a ST+ acute coronary syndrome with a confirmation of acute myocardial infarction during their hospital stay were prospectively enrolled into this study. A questionnaire was administered by phone from december 2003 to july 2005, assessing the knowledge about the necessity to alert SAMU-center 15 in case of chest pain and availability of medical files data. RESULTS: among the 976 patients: 111 (11%) were lost during follow-up, 162 (19%) were deceased when phone contact and 119 (12%) could not be interrogated. Among the 584 (60%) remaining subjects interrogated with a median follow-up period of 985 days (413-1596), 290 (50%) patients answered they received counseling, including 156 (27%) for taking nitrates, 19 (29%) stated they know that they should call SAMU-center 15. Patients with a high level of education and those treated by thrombolytic therapy prior to hospitalization were better informed; 464 (79%) patients declared having a prescription, 392 (67%) a hospital report, 406 (69%) an electrocardiogram, 227 (39%) a CD with their coronary angiography, and 79(14%) their medical file. CONCLUSION: the level of knowledge regarding the recommended attitude in case of chest pain is poor. The availability of medical data was better. Arch Mal Cceur

[Pre-hospital management of acute coronary syndromes with ST elevation in the Ile-de-France Region: the E-MUST registry]. / Prise en charge préhospitalière des syndromes coronaires aigus ST+ en île-de-France. Le registre E-MUST.

The E-MUST registry gathers patient data from the emergency ambulance service of the IIe-de-France for acute coronary syndromes with ST elevation seen within 24 hours from onset of symptoms. The parameters include the type of emergency phone call, details relative to the different phase of management, decisions of therapeutic strategy concerning pre-hospital thrombolysis or primary angioplasty and the different factors influencing these decisions. From January 2001 to June 2002, the mean delay from the onset of symptoms and the call-out of the emergency ambulance was 67.5 minutes for the 2584 patients studied. In this group, a pre-hospital decision for coronary revascularisation was taken in 84.3% of cases, pre-hospital thrombolyis started 33 minutes after arrival of the ambulance (32.7% of cases) and primary angioplasty carried out 81 minutes after that arrival (51.6% of cases). Decisions for revascularisation were less common in the elderly and those seen over 6 hours after the onset of symptoms. Pre-hospital management allows decisions concerning coronary reperfusion to be taken more often and earlier in patients with acute coronary syndromes.

Measurement of carbon monoxide in simulated expired breath.

BACKGROUND: Environmental carbon dioxide (CO) detectors used as an early warning method have been adapted to measure CO concentration in expired breath. This technique has been validated in smokers with relatively low CO concentrations, but its applicability to poisoning has not been demonstrated. OBJECTIVE: To compare the reliability of toxicologically significant CO measurements performed using a portable CO detector with those obtained using infrared spectrometry, the standard method for blood CO concentration determination. DESIGN: Experimental study with a CO detector and infrared spectrometer. A balloon simulated respiratory movements and an expired breath. Balloon gas mixtures contained CO, in one of 21 different concentrations from 100 to 600 parts per million (ppm) in air. CO concentration was measured directly with the portable CO detector and two gas samples obtained at the beginning and end of the simulated expired breath were diluted, with validation, for spectrometric measures. MAIN OUTCOME MEASURES: Portable CO detector concentrations were compared with the mean value of the reference method. Simple linear regression was performed using ANOVA to evaluate the parallel between the model with the reference method. RESULTS: Portable CO detector concentration measurements were perfectly linear (R2=0.989, P<10(-3)) over a concentration range of 46-645 ppm. The difference from the reference plot was significant (P<0.01). CONCLUSION: Given the linearity of the measurements, the underestimation by the portable CO detector at higher concentrations can be corrected mathematically. A portable CO detector should measure CO in expired breath efficiently and reliably.

[Victims of fall from height. Study of 287 patients and determination of clinical prognostic factors]. / Patients victimes de chutes de grande hauteur. Etude d'une cohorte de 287 patients et détermination des facteurs pronostiques cliniques.

INTRODUCTION: Fall from height is a common cause of severe blunt urban trauma but this mechanism of trauma is poorly documented. OBJECTIVE: To describe initial clinical parameters, injuries and outcome in patients victims of falls from height and to determinate clinical prognostic factors. STUDY DESIGN: Retrospective study from January 1998 to May 1999 and prospective study from June 1999 to September 2000. Inclusions: patients older than 12 year-old victims of falls with height of more than 3 m. PATIENTS AND METHODS: Studied parameters: demographic data, fall circumstances, prehospital clinical evaluation (Glasgow coma scale (GCS), Arterial Blood Pressure (ABP), Heart Rhythm (ER) and revised trauma score (RTS) initial and patients outcome. RESULTS: Two hundred and eighty seven patients were included during 32.5 months; 33% were women and 67% men. Mean age: 37 +/- 16 years. Median height of fall: three stairs (3-4). Final mortality: 34% including 22% death on site with or without resuscitation, 5% before hospitalization, 8% during the first day and 2% later. Independent prognostic factors were GCS (OR = 0.40; IC: 0.25 - 0.65; P = 0.0002), initial ABP (OR = 0.94; IC: 0.90 - 0.98; P = 0.008) and RTS (OR = 2.93; 1.19-7.24; P = 0.02). CONCLUSION: Immediate mortality after fall from heights is high and remains low after day 3. GCS, ABP and RTS are independent prognostic factors.

[Impact of the law of the 4 March 2002 relative to patients' rights on request for medical information received in a medical dispatching center and mobile intensive care unit (Samu 93)]. / Impact de la loi du 4 mars 2002 relative aux droits des malades sur les demandes d'informations médicales reçues au Samu 93.

INTRODUCTION: Law of the 4 March 2002 allowed patient's access to his medical record. This law could increase the number of requests in medical dispatching centers and prehospital intensive care units. OBJECTIVE: The aim of this study was to evaluate the impact of this law on the number of requests for medical information received in our unit. METHODS: Since the promulgation of the law, from March to December 2002, medical requests were prospectively collected and classified in categories including request for transmission of medical record. Requests received before the law, from January 2000 to February 2002 were classified according to the same items. Number of requests received during the two periods were compared according to the total number of medical record managed in our medical dispatching center and prehospital intensive care unit. RESULTS: The total number of requests for medical information significantly increased since the law of March 2002 (results are expressed as cases per month per 10 000 record: 4.8 +/- 2.5 vs. 8.0 +/- 4.5; p = 0.04). Specific request for transmissions of medical record significantly increased since the law (1.3 +/- 1.6 vs. 3.0 +/- 3.0; P = 0.046). This increase was progressive and constant since March 2002. DISCUSSION: Physicians and patients should take in consideration consequences of this law. Physician should be vigilant with the quality of their medical dossiers. Interpretation of this law and its ethics consequences will probably be discussed again as one should not exclude perverse impact of this law. In effect, insurances and mutual insurances companies could find in this law a way to obtain medical information, such as circumstances of death, previously unavailable. CONCLUSION: The law of 4 March 2002 relative to patients' rights significantly increased number of requests for medical information received in our dispatching center and prehospital intensive care unit.

Stroke associated with pulmonary embolism after air travel.

Prolonged air travel is associated with an increased incidence of thromboembolic events. The occurrence of stroke was studied in patients with pulmonary embolism after air travel in a review of all flights arriving at Charles de Gaulle Airport in Paris during an 8-year period. Thromboembolic stroke and patent foramen ovale were diagnosed in four patients with pulmonary embolus.

[Organization of medical rescue during catastrophes with limited effects occurring in urban areas]. / Organisation des secours médicaux lors de catastrophes à effets limités en milieu urbain.

OBJECTIVE: We conducted a survey regarding the organization of medical rescue during major events (catastrophes with limited effects) occurring in urban areas (Paris and immediate suburbs). The goal of this work was to study the availability of on site medical help and the real needs.Study design - Retrospective survey. METHODS: Thirty-eight major events were analysed between 1988 and 2000. The median number (25th-75th percentiles) of victims per event was 42 (21-68) (range 8 to 424). RESULTS: The median percentage of true emergencies (TE) was 5% with regard to the total number of victims per event. Thirty minutes after the event, 92% of the sites had a number of physician-manned ambulances greater than the number of severe victims. The median time to first evacuation was 79 (62-102) min. CONCLUSION: Disasters with limited effect occurrence in Paris and its immediate suburbs are characterized by a small percentage of TE and by a constant oversupply of medical means onsite. These observations led us to propose a new organization of medical rescue during this type of catastrophe, abandoning the classical notion of forward medical command post (FMCP) for a collection point of medical services (CPMS) consisting all means of evacuation (physician-manned and other ambulances). Also, a new type of victim identification, based on hospital base-station medical direction is discussed in this paper.

Severe pulmonary embolism associated with air travel.

BACKGROUND: Air travel is believed to be a risk factor for pulmonary embolism, but the relation between pulmonary embolism and distance flown has not been documented. The aim of this study was to investigate whether the duration of air travel is related to the risk of pulmonary embolism. METHODS: From November 1993 to December 2000, we systematically reviewed all cases of pulmonary embolism requiring medical care on arrival at France's busiest international airport. Data on the geographic origins of all flights and the numbers of passengers were collected in order to evaluate the incidence of pulmonary embolism per 1 million passenger arrivals as a function of the distance traveled. RESULTS: A total of 135.29 million passengers from 145 countries or other areas arrived at Charles de Gaulle Airport during the period of the study, of whom 56 had confirmed pulmonary embolism. The incidence of pulmonary embolism was much higher among passengers traveling more than 5000 km (3000 mi) (1.5 cases per million, as compared with 0.01 case per million among those traveling less than 5000 km). The incidence of pulmonary embolism was 4.8 cases per million for those traveling more than 10,000 km (6000 mi). CONCLUSIONS: A greater distance traveled is a significant contributing risk factor for pulmonary embolism associated with air travel.

[Availability of antidotes in French emergency medical aid units]. / Disponibilité des antidotes dans l'aide médicale urgente.

OBJECTIVE: To study the availability of antidotes in French emergency medical aid units (SAMU). METHODS: The physicians or nurses responsible for antidotes in French emergency medical aid units (SAMU) were interviewed by phone. The study involved 102 SAMU in metropolitan France. Four answers on availability of 37 antidotes were possible: the antidote was available in the emergency vehicle used for interventions; the antidote was available in the hospital-located SAMU; the antidote was available in the referral hospital (emergency unit, intensive care unit, operating room, pharmacy); the antidote was not available or not known to be available. RESULTS: Adrenaline and atropine were available in all the intervention vehicles. Nine other antidotes were available in more than two-thirds of the vehicles: 30% glucose (101/102), isoprenaline (100/102), dobutamine (98/112), sodium bicarbonate (97/102), naloxone (95/102), calcium chloride or bicarbonate (89/102), flumazénil (83/102), sodium lactate (77/102), and magnesium sulfate (66/102). Among the other antidotes, hydroxocobalamine and propranolol were available in 24/102 intervention vehicles and activated charcoal in 22/102. Antidigitalic antibodies and 4-methylpyrazole were not available in any vehicle, and were available in less than 25% of the hospitals. CONCLUSION: There is a great disparity of antidote availability. Certain essential antidotes, for which there is no alternative, are not available in emergency intervention vehicles and even in the hospital. The SAMU should develop an economically acceptable departmental management scheme for exceptional-use antidotes.

[Measurement of carbon monoxide in expired breath in prehospital management of carbon monoxide intoxication]. / Intérêt du dosage du monoxyde de carbone dans l'air expiré au cours de la prise en charge préhospitalière des intoxications oxycarbonées.

INTRODUCTION: Carbon monoxide detectors are currently used by the French prehospital medical teams. These detectors can also be used to measure expired breath carbon monoxide concentration. The interest of this measurement has never been studied. OBJECTIVE: To evaluate interest of expired breath carbon monoxide concentration measurement in the management of prehospital carbon monoxide intoxication. STUDY DESIGN: Patients with carbon monoxide poisoning were included during 1998. PATIENTS AND METHODS: Four levels of clinical severity: no symptom, minor, medium or severe intoxication were defined. Carbon monoxide concentration were measured in the expired breath (COHbe) at the place of the intoxication and in blood samples collected at the place of the intoxication (COHbs) and at the hospital (COHbh). RESULTS: 209 patients were included, 144 had no symptom (55%), the value of COHbe was 11.6 +/- 7.5% (mean +/- DS) and the value of COHbh was 4.9 +/- 3.3%. 91 patients had minor intoxication (35%), the value of COHbe was 16.4 +/- 7.9% and the value of COHbh was 7.1 +/- 4.5%, 21 patients had sever or medium intoxication (8%) the value of COHbe was 26.4 +/- 17.7% and the the value of COHbh was 12.8 +/- 9.3%. Results for COHbh were obtained for only three patients. Relationship between symptoms and expired breath carbon monoxide and relationship between symptoms and carbon monoxide blood concentration on arrival at the hospital were significant (p < 0.05). CONCLUSION: Measurement of expired carbon monoxide concentration, easy and quick to perform is correlated with clinical severity in carbon monoxide poisoning.

Study of the "sniffing position" by magnetic resonance imaging.

BACKGROUND: The "sniffing position" is widely considered essential to the performance of orotracheal intubation and has become the cornerstone of training in anesthesiology. However, the anatomic superiority of this patient head position has not been established. METHODS: Eight healthy young adult volunteers underwent magnetic resonance imaging scanning in three anatomic positions: head in neutral position, in simple extension, and in the "sniffing position" (neck flexed and head extended by means of a pillow). The following measurements were made on each scan: (1) the axis of the mouth (MA); (2) the pharyngeal axis (PA); (3) the laryngeal axis (LA); and (4) the line of vision. The various angles between these axes were defined: alpha angle between the MA and PA, beta angle between PA and LA, and delta angle between line of vision and LA. RESULTS: Both simple extension and sniffing positions significantly improved (P < 0.05) the delta angle associated with best laryngoscopic view. Our results show that the beta value increases significantly (P < 0.05) when the head position is shifted from the neutral position (beta = 7 +/- 6 degrees ) to the sniffing position (beta = 13 +/- 6 degrees ), and the alpha value slightly (but significantly) decreases (from 87 +/- 10 degrees to 63 +/- 11 degrees; P < 0.05). Anatomic alignment of the LA, PA, and MA axes is impossible to achieve in any of the three positions tested. There were no significant differences between angles observed in simple extension and sniffing positions. CONCLUSIONS: The sniffing position does not achieve alignment of the three important axes (MA, PA, and LA) in awake patients with normal airway anatomy.

[Rapid sequence anesthetic induction via prehospital tracheal intubation]. / Induction anesthésique en séquence rapide pour l'intubation trachéale préhospitalière.

The choice of sedation for emergency intubation remains controversial. This lack of consensus has led to various sedation protocols used in French prehospital care setting. A review of data from the literature suggests that the association etomidate-suxamethonium is probable the best choice for rapid sequence intubations in the prehospital setting. Its benefits include protection against myocardial and cerebral ischaemia, decreased risk of pulmonary aspiration, and a stable haemodynamic profile. Randomized studies are needed to substantiate the advantages of the association etomidate-suxamethonium for rapid sequences intubation in the prehospital setting.

Emergency tracheal intubation of patients lying supine on the ground: influence of operator body position.

PURPOSE: To evaluate the influence of operator body position during emergency intubation of patients lying on the ground. METHODS: This study was carried out in the prehospital setting by French mobile intensive care units. Two operator body positions (left lateral decubitus and kneeling) for emergency intubation of patients lying supine on the ground were compared in a observational prospective study. Each operator completed a questionnaire regarding conditions of intubation after patient completion. RESULTS: The incidence of laryngoscopic difficulty was lower in the left lateral decubitus group compared to the kneeling group (11.1% vs 26.9% respectively; P < 0.01). The number of attempts required for successful intubation was (P < 0.05) higher in the kneeling group than in the left lateral decubitus group. CONCLUSION: Emergency tracheal intubation of supine patients on the ground may be greatly facilitated by the use of the left lateral decubitus position of the operator.

Intubation difficulty in poisoned patients: association with initial Glasgow Coma Scale score.

OBJECTIVE: To determine whether the initial Glasgow Coma Scale (GCS) score is predictive of intubation difficulty in out-of-hospital airway management of poisoned patients. METHODS: A prospective, observational study was performed in a toxicological intensive care unit of a university hospital and in a physician-based out-of-hospital care system. Subjects included consecutive poisoned patients intubated during their airway management by out-of-hospital medical teams before hospitalization. The intubating operator (emergency physician or nurse anesthetist) completed a 1-page checklist concerning the clinical parameters and circumstances (nature of sedation and difficulty) of endotracheal intubation upon hospital arrival. RESULTS: Forms were completed for all 394 consecutive out-of-hospital intubations. The patients ranged from 15 to 95 years of age (median age 38 years). Most (96%) of the intubations were via the oral route. Intubation difficulty was related to GCS values. Intubation difficulty was seen more often in patients with 7 < or = GCS < or = 9 (36%) than in patients with GCS < 7 (15%) or > 9 (10%). Not surprisingly, perceived intubation difficulty was least for those patients undergoing rapid-sequence intubation rather than administration of sedation alone. CONCLUSION: Maximum difficulty of intubation is encountered in poisoned patients with 7 < or = GCS < or = 9. Intubation of such patients appears to be facilitated by appropriate sedation and/or neuromuscular blockade.

A survey of sedation protocols used for emergency endotracheal intubation in poisoned patients in the French prehospital medical system.

The purpose of this study was to evaluate prehospital sedation protocols used by several French mobile intensive care units for difficult intubations in poisoned patients. This prospective, descriptive study was performed within the toxicological intensive care unit in a university hospital. Consecutive poisoned patients intubated during their airway management by prehospital medical teams were included. Intubating physicians completed a one-page checklist concerning the circumstances of endotracheal intubation. Intubation difficulty was significantly related to the nature of sedation protocols. The use of etomidate alone as an intubation sedative agent was associated with significantly poorer intubating conditions (47.2% difficult) than other sedative agents or neuromuscular blockade). Neuromuscular blockade with sedation in our series was associated with the lowest incidence of difficult intubations in poisoned patients. Sedation alone for intubation appears to be inadequate to achieve good intubating conditions in a significant proportion of patients.